Benign tumors of jaw

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radio-graphical description of benign tumors of jaw

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Benign tumors of Benign tumors of jawjaw

MODERATED BY: DR. SUNITA GUPTA DR. SHALINI DR. DEEPMALA DR. VIPUL DR. ANSHUM

By:

VARUN SURYA

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The term " benign " implies mild and non-progressiveA benign tumor is a tumor that lacks all three of the malignant properties of a cancer. Thus, by definition, a benign tumor does not grow in an unlimited , aggressive manner, does not invade surrounding tissues , and does not metastasize.

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Features Benign tumor Malignant tumor

Periphery Smooth, well defined, Encapsulated, corticated

Ill defined border, lack of cortication , absence of encapsulation

Surrounding tissue Compressed Invaded

Size Usually small Often larger

Growth rate Slow Rapid

Spread Direct extension Metastasis

Location Specific anatomic site

Anywhere

Internal structure RO , RL , mixed Radiolucent

Effect on surrounding

Resorb teeth root , displace teeth in a bodily fashion without causing loose teeth

Destroy supporting alveolar bone so that teeth may appear floating in space

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Benign tumors represent a new uncoordinated growth Benign tumors are slow-growing and spread by direct extension and not by metastases.They tend to resemble the tissue of origin histologically.It is thought that benign tumors have unlimited growth potential. Often hamartomas are included in the category of benign tumors. However, hamartomas are overgrowths of disorganized normal tissue that have a limited growth potentialFor example, an odontoma is a hamartoma of dental tissue .other are hemangioma , lymhangioma

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Clinical Features  Benign tumors typically have an insidious onset and

grow slowly.These tumors usually are painless ,do not metastasize, and are not life threatening unless they interfere with a vital organ by direct extension. Benign tumors are usually detected clinically by enlargement of the jaws or are found during a radiographic examination.

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Radiologic featuresLOCATION Many tumors have a specific anatomic predilection odontogenic

lesionsoccur in the alveolar processes Above the inferior alveolar nerve canal, where tooth formation occurs

Vascular and neural lesions

may originate inside the mandibular canal, arising from the Neurovascular tissues

Cartilaginous tumors

occur in jaw locations where residual cartilaginous cells lie, such as around the mandibular condyle.

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PERIPHERY AND SHAPE Benign tumors enlarge slowly by formation of additional internal tissue.Because of this, the radiographic borders of benign tumors appear relatively smooth, well defined, and sometimes corticated. If the tumor produces a calcified product-for example, abnormal tooth material or abnormal bone-the most mature part of the tumor will be in the central region with the most immature aspect at the periphery. This sometimes results in a radiolucent band of soft tissue or capsule at the periphery where the calcified product has not yet formed; this band separates the more mature internal radiopaque portion from the surrounding normal bone.

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INTERNAL STRUCTURE It may be completely radiolucent or radiopaque or maybe a mixture of radiolucent and radiopaque tissues. If the lesion contains radiopaque elements, these structures usually represent either residual bone or a calcified material that is being produced by the tumor. For instance curved septa that are characteristic in ameloblastoma represent residual bone trapped inside the tumor that has remodeled into curved septa. The ameloblastoma does not produce bone. . 8

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EFFECTS ON SURROUNDING STRUCTURES a benign tumor exerts pressure on neighboring structures, resulting in the displacement of teeth or bony cortices. If the growth is slow enough, there will be adequate time for the outer cortex to remodel in response to the pressure,resulting in an appearance that the cortex has been displaced by the tumor .This is caused by simultaneous resorption of bone along the inner surface (endosteal) of the cortex and deposition of bone along the outer cortical surface by the periosteum Through this remodeling process, the cortex maintains its integrity and resists perforation. Benign tumors may also cause bodily displacement of near by teeth .

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The roots of teeth maybe resorbed by either benign or malignant tumors, but root resorption more commonly is associated with benign processes.The benign tumors especially likely to resorb roots are ameloblastomas, ossifying fibromas, and central giant cell granulomas.

Benign tumors tend to resorb the adjacent root Surfaces in a smooth fashion. When root resorption is associated with malignant tumors, the resorption is usually in smaller quantities causing thinning of the root into a "spiked" shape.

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Benign tumorsThe benign neoplasias are separated into two major groups: odontogenic tumors and non-odontogenic tumors.

ODONTOGENIC TUMORS Odontogenic tumors arise from the tissues of the odontogenic apparatusAccording to (WHO),

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1). Odontogenic epithelium (i). Ameloblastoma (ii). Squamous odontogenic tumor (iii).Calcifying epithelial

odontogenic tumor (Pindborg’s tumor)

(iv).Clear cell odontogenic tumor 2). Odontogenic epithelium with odontogenic ectomesenchyme (i). Ameloblastic fibroma (ii). Ameloblastic fibro dentinoma and

ameloblastic fibro odontoma (iii). Odontoameloblastoma (iv). Adenomatoid OdontogenicTumor (v). Calclifying odontogenic cyst (vi). Complex odontoma (vii). Compound odontoma 14

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3). Odontogenic ectomesenchyme

(i). Odontogenic fibroma (ii). Myxoma / Odontogenic myxofibroma (iii).Benign cementoblastoma

( True Cementoblastoma)

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Odontogenic epithelial tumors

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AMELOBLASTOMA Synonyms Adamantinoma , adamantoblastoma, and epithelial odontoma DefinitionA true neoplasm of enamel organ type which doesn’t undergo differentiation to the point of enamel formation.

robinson Defined it asA tumor that is -Unicentric, non functional, intermittent in growth, anatomically benign and clinically persistent

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Clinical featuresAge - 20 to 40yrsSite - mandible > maxillaslow growing, painless, bony expansioninitially Tennis ball like consistency

“Egg shell” like cracking

Jaw bone enlargement & parasthesia

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Radiographic Features Location. Most (80%) develop in the molar-ramus region of the mandible, but they may extend to the symphyseal area. Periphery. is usually well defined and frequently delineated by a cortical border. The border is often curved and in small lesions the border and shape may be indistinguishable from a cyst The periphery of lesions in the maxilla is usually- more ill defined. 20

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Internal structure. The internal structure varies from totally radiolucent to mixed with the presence of bony septa creating internal compartments. These septa are usually coarse and curved and originate from normal bone that has been trapped within the tumor. Because this tumor frequently has internal cystic components, these septa are often remodeled into curved shapes providing a honeycomb (numerous small compartments or loculations) or soap bubble (larger compartments of variable size)patterns . Generally the loculations are larger in the posterior mandible and smaller in the anterior mandible.

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Egg shell

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Effects on surrounding structures. There is pronounced tendency for ameloblastomas to cause extensive root resorption . Tooth displacement is common. Because a common point of origin is occlusal to a tooth, some teeth may be displaced apically. An occlusal radiograph may demonstrate cyst like expan- sion and thinning of an adjacent cortical plate, leaving a thin "egg-shell" of bone . Actual perforation of bone into the surrounding soft tissues or anatomic spaces is a late feature of ameloblastomaUnicystic types of ameloblastoma may cause extreme expansion of the mandibular ramus

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Differential Diagnosis The odontogenic keratocyst may contain curved septa but usually the keratocyst tends to grow along the bone without marked expansion, which is Characteristic of ameloblastomas.

 

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Giant cell granulomas generally occur anterior to the molars, occur in a younger age group, and have more granular and ill defined septa

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Odontogenic myxomas may have similar appearing septa; however , there are usually one or two thin, sharp, straight septa, characteristic of the myxoma. Even the presence of one such septum may indicate a myxoma. Also myxomas are not as expansile as ameloblastomas and tend to grow along the bone.

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The septa in ossifying fibroma are usually wide, granular, and ill defined. Also, look for the presence of small irregular trabeculae.

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Treatment The most common treatment is surgical resection. If the ameloblastoma is relatively small , it may be removed completely by an intraoral approach and larger lesions May require resection of the jaw. The maxilla is usually treated more aggressively because of the tendency of ameloblastoma to invade adjacent vital structures. Radiation therapy may be used for inoperable tumors, Especially those in the posterior maxilla. 30

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CALCIFYING EPITHELIUM ODONTOGENIC TUMOR

( Pindborg’s tumor )Definition:It is a locally aggressive tumor consist of sheets & strands of polyhedral cells in fibrous stroma with no inflammatory component & are often accompanied by spherical calcifications & amyloid staining hyaline deposits.Origin -Rest of dental lamina -Reduced enamel epithelium1% of all odontogenic tumor

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Clinical features CEOT

Central Peripheral(intraosseous) (extraosseous)age - 40yrs site - anterior gingivasite - 2/3rd of appears as superficiallesions in mandible soft tissue swelling slow growing. of gingiva in a tooth painless mass. bearing area or edentulous area

of jaw

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Radiographic features:

Location. mandible most develop in the premolar-molar area, with a 52% association with an unerupted or impacted tooth. Periphery. The border may have a well-defined cyst like cortex. In some tumors the boundary maybe irregular and ill defined Internal structure. The internal aspect may appear unilocular or multilocular with numerous scattered, radiopaque foci of varying size and density. The most characteristic and diagnostic finding is the appearance of radiopacities close to the crown of the embedded tooth .

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most characteristic and diagnostic finding is the appearance of radiopacities close to the crown of the embedded tooth

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Effects on surrounding structures. may displace a developing tooth or prevent its eruption. Associated expansion of the jaw with maintenance of a cortical boundary may also occur. Differential Diagnosis Lesions with completely radiolucent internal structure may mimic dentigerous cysts or even ameloblastomasOther lesions with radiopaque foci, including ade- nomatoid odontogenic tumor, ameloblastic fibro- odontoma, and calcifying odontogenic cyst , may have similar appearances. However , the prominent location of the CEOT and the age of the patient will help in the differential diagnosis.

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 Treatment The treatment of the CEOT is more conservative than the ameloblastoma , with local resection

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MIXED TUMORS (OF ODONTOGENIC

EPITHELIUM AND ODONTOGENIC

ECTOMESENCHYME)

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ODONTOMAMost common type of odontogenic tumorDefinition:a tumor that is radiographically and histologically characterized by the production of mature enamel, dentin, cementum,and pulp tissue.Clinical features:Age- 10 to 20yrsSite - Maxilla > mandibleSlow growing , hard , painless mass

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GARDNER’S Syndrome is associated with it (a). Multiple odontomas (b). Multiple osteomas (c ). Intestinal polyps (d). Epidermoid cyst (e). Dermoid tumor(fibrous) 2 Types (1). Complex (2). Compound

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Features Compound complex

location anterior maxilla in association with the crown of an unerupted canine.

mandibular first and second molar area.

Internal structure number of toothlike structures or denticles that look like deformed teeth

irregular mass of calcified tissue

Frequency More Less common

Sex predilection M=F More in female

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Radiographic Features Location. compound odontomas (62%) occur in the anterior maxilla in association with the crown of an unerupted canine. 70%of complex odontomas are found in the mandibular first and second molar area.  Periphery. The borders of odontomas are well defined and may be smooth or irregular. These lesions have a cortical border and immediately inside and adjacent to the cortical border is a soft tissue capsule.

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 Internal structure. The contents of these lesions are largely radiopaque. Compound odontomas have a number of toothlike structures or denticles that look like deformed teeth Complex odontomas contain an irregular mass of calcified tissue Effects on surrounding structures. Odontomas ,can interfere with the normal eruption of teeth. Most odontomas (70%) are associated with abnormalities such as impaction, malpositioning, diastema, aplasia, malformation, and devitalization of adjacent teeth. Large complex odontomas may cause expansion of the jaw with maintenance of the cortical boundary.

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Complex odontoma

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Compound odontoma

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treatment Complex and compound odontomas are usually Removed by simple excision. They do not recur and are not locally invasive

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AMELOBLASTIC FIBROMA Synonyms Soft odontoma, soft mixed odontoma, mixed odonto genic tumor, fibroadamantoblastoma,and granular cell AmeloblasticfibromadefinationAmeloblastic fibromas are benign, mixed odontogenic tumors. They are characterized by neoplastic prolifera- tion of maturing and early functional ameloblasts,as well as the primitive mesenchymal components of the dental papilla. Enamel, dentin, and cementum are not formed in this tumor.

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Clinical features:Age- 5 to 20yrsSite - Maxilla > mandibleSex- no sex predilectionThey usually produce a painless,slow-growing expan- sion, and displacement of the involved teeth Radiographic Features Location. in the premolar-molar area of the mandiblePeriphery. The borders of an ameloblastic-fibroma are well defined and often corticated in a manner similar to that of a cyst.

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Internal structure. An ameloblastic fibroma is more commonly unilocular (totally radiolucent)  Effects on surrounding structures. If the lesion is large, there may be expansion with an intact cortical plate. The associated tooth or teeth may be inhibited from normal eruption or may be displaced in an apical direction.  

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Differential Diagnosis Ameloblastoma—however ,the ameloblastic fibroma occurs at an earlier age and the septa in an ameloblastoma are more defined and coarse. In fact the septa in ameloblastic fibroma are infrequent and often very fine. Giant cell granulomas --may appear multilocular, but these tumors usually have an epicenter anterior to the first molar and the septa are characteristically granular and ill defined. Odontogenic myxomas-- can appear multilocu- lar but usually a few sharp straight septa can be identi- fied, which are not characteristic of ameloblastic fibromas and myxomas usually occur in an older age group.

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 Treatment. Ameloblastic fibromas are benign, and the rate of recurrence is low. A conservative surgical approach,including enucleation and mechanical curettage of the surrounding bone,

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AMELOBLASTIC FIBRO-ODONTOMA Definition An ameloblastic fibro-odontoma is a mixed tumor with all the elements of an ameloblastic fibroma but with Scattered collections of enamel and dentineClinical Features.The clinical features are similar to odontomas, often associated with a missing tooth or tooth that has failed to erupt. This tumor appears during the same age as odontomas and ameloblastic fibromas with no particular sex predilection.

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Radiographic Features Location-posterior aspect of the mandible. The epicenter of the lesion is usually occlusal to a developing tooth or toward the alveolar crest.  Periphery. This tumor is usually well defined and some- times corticated. Internal structure. The internal structure is mixed, with the majority of the lesion being radiolucent. Small lesions may appear as enlarged follicles with only one or two small,discrete radiopacities. Larger lesions may have a more extensive calcified internal structure

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Differential Diagnosis Differentiation from a developing odontoma may be difficult, but generally these tumors have a greater soft tissue component (radiolucent) than an odontomaA complex odontoma, which shares a common location, usually has one mass of disorganized tissue in the center, whereas the ameloblastic fibro- odontoma will usually have multiple scattered mature small pieces of dental hard tissueTreatment Usually conservative enucleation is used 58

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ADENOMATOID ODONTOGENIC TUMORSynonyms , Adenoameloblastoma and ameloblastic adenomatoid tumor  Definition Adenomatoid odontogenic tumors are uncommon, Nonaggressive tumors of odontogenic epithelium

Clinical featuresAge - younger patient (10 to 19yrs).Sex - femaleSite - anterior portion of the jaw maxilla > mandibleAsymptomatic, painless, slow growing.large lesions causes expansion of bone.

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Both central and peripheral tumors occur. The central tumors are divided into the follicular type (those associated with the crown of an embedded tooth) and the extra- follicular type (those with no embedded tooth). Radiographic Features Location. At least 75% occur in the maxilla

The incisor canine-premolar region, especially the canine regionPeriphery. The usual radiographic appearance is a well- defined corticated or sclerotic border.  Internal structure. Radiographically, radiopacities develop in about two thirds of cases

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Effects on surrounding structures. As the tumor enlarges, adjacent teeth are displaced. Root resorption is rare. This lesion also may inhibit eruption of an involved tooth. Although some expansion of the jaw may occur, the outer cortex is maintained. Differential DiagnosisIf the attachment of the radiolucent lesion is more apical than the cementoenamel junction, a follicular cyst can be discounted.The ameloblastic fibro-odontoma and the calcifying epithelial odontogenic tumor occur more commonly in the posterior mandible.

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Pebble –like calcification

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Treatment Conservative surgical excision is adequate because the tumor is not locally invasive,is well encapsulated,and is separated easily from the bone

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MESENCHYMAL TUMORS  

(ODONTOGENIC ECTOMESENCHYME)

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ODONTOGENIC MYXOMA Synonyms  Myxoma, myxofibroma, and fibromyxoma Definition Odontogenic myxomas are uncommon, accounting for only 3% to 6% of odontogenic tumors. They are benign, intraosseous neoplasms that arise from odon- togenic ectomesenchyme and resemble the mesenchy- mal portion of the dental papilla

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Clinical featuresAge - 10 to 30yrs.Sex – femaleThe tumor grows slowly and may or may not cause pain.Eventually it causes swelling and May grow quite large if left untreated

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Radiographic Features Location- mandible , the premolar and molar areas Periphery--The lesion usually is well defined, and it may have a corticated margin but most often is poorly defined, especially in the maxillaInternal structure. majority have a mixed radiolucent-radiopaque internal pattern. Residual bone trapped within the tumor will remodel into curved and straight, course or fine septa.The pres- ence of these septa gives the tumor a multilocular appearance. A characteristic septa identified with this tumor is a straight, thin-etched septa

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The majority of the septa are curved and course, but the finding of one or two of these straight septa will help in the identification of this tumorEffects on surrounding structures. When growing in a tooth-bearing area, it displaces and loosens teeth, but rarely causes resorption of teeth. The lesional so frequently scallops between the roots. of adjacent teeth similar to a simple bone cyst. This tumor has a tendency to grow along the involved bone without the same amount of expansion seen with other benign tumors.

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Differential Diagnosis Include ameloblastomas, central giant cell granulomas, and central hemangiomas. The finding of characteristic thin, straight septa with less-than-expected bone expansion is very useful in the differential.Careful inspection of this area of expansion will reveal a thin but intact outer cortex that would not be seen in osteogenic sarcomaTreatment by resection with a generous amount of surrounding bone to ensure removal of myxomatous tumor that infiltrates the adjacent marrow spaces.

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BENIGN CEMENTOBLASTOMA Synonyms Cementoblastoma and true cementoma Definition Benign cementoblastomas are slow-growing , mesenchymal neoplasms composed principally of cementum  Clinical Features Age - 12 to 65Sex - femalesThe tumor usually is a solitary lesion that is slow-growing but that may eventually displace teeth. The involved tooth is vital and often painful. The pain seems to vary from patient to patient and can be relieved by anti-inflammatory drugs.

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Radiographic Features Location. mandible (78%) -premolar or first molar(90%). Periphery. The lesion is a well-defined radiopacity with a cortical border and then a well-defined radiolucent band just inside the cortical borderInternal structure. mixed radiolucent-radiopaque lesions in which the majority of the internal structure is radiopaque. wheel spoke pattern The density of the cemental mass usually obscures the outline of the enveloped root. This central radiopaque mass as mentioned is surrounded by a radiolucent band indicating that the tumor is maturing from the central aspect to the periphery.

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Effects on surrounding structures. If large enough, this tumor can cause expansion of the mandible but with an intact outer cortex.  Differential Diagnosis the radiolucent band around the benign cementoblastoma is usually better defined and more uniform than with cemental dysplasia.Also, in the first molar region the cementoblastoma has a more rounded shape than cemental dysplasia. Treatment Benign cementoblastomas are apparently self-limiting and rarely recur after enucleation. Simple excision and extraction of the associated tooth are sufficient treatment

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CENTRAL ODONTOGENIC FIBROMA Synonyms Simple odontogenic fibroma and odontogenic fibroma (World Health Organization [WHO] type) Definition Central odontogenic fibromas are rare neoplasms that Sometimes are divided into two types according to his- tologic appearance: simple type contains mature fibrous tissue with sparsely scattered odontogenic epithelial rests; WHO type, which is more cellular, Has more epithelial rest sand may contain calcifications that resemble dysplastic dentin, cementum, or osteoid.

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Clinical Features Age - 11 and 39 yearsSex – femalespatients may be asymptomatic or may have swelling and mobility of the teeth. Radiographic Features Location. mandible, molar-premolar region. They are also prevalent in the maxilla anterior to the first molar.  Periphery. The periphery usually is well defined,  Internal structure. Smaller lesions usually are unilocu- lar, and larger lesions have a multilocular pattern. The internal septa may be fine and straight, as in odonto- genic myxomas,or it maybe granular, resembling those Seen in giant cell granulomas.

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Effects on surrounding structures. A central odontogenic fibroma may cause expansion with maintenance of a thin cortical boundary or on occasion can grow along the bone with minimum expansion similar to an odontogenic myxoma. Tooth displacement is common, and root resorption has been reported. Differential Diagnosis Desmoplastic fibromas are more aggressive and tend to break through the peripheral cortex and invade surrounding soft tissue

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NONODONTOGENIC TUMORS

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BENIGN TUMORS OF NEURAL ORIGIN NEURILEMOMASynonym Schwannoma  Definition A central neurilemoma is a tumor of neuro-ectodermal origin, arising from the Schwann cells that make up the inner layer covering the peripheral nerves. Clinical Features

Age – second and third decadesSex – equal frequency

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The usual complaint is a swelling. Pain, when present, usually develops at the Site of the tumor; if paresthesia occurs,it is felt anterior to the tumor.  Radiographic Features Location. mandible, most often located within an expanded inferior alveolar nerve canal posterior to the mental foramen Periphery. In keeping with its slow growth rate, the margins of this tumor are well defined and usually cor- ticated as it expands the cortical walls of the inferior alveolar canal. Small lesions may appear cystlike but more commonly are fusiform in shape as the tumor expands the canal.

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Internal structure. The internal structure is uniformly radiolucent. When lesions have a scalloping outline, this may give a false impression of a multilocular pattern. Effects on surrounding structures. If the tumor reaches either the mandibular foramen or mental foramen, it can cause enlargement of the foramen. Expansion of the inferior alveolar canal is slow and thus the outer cortex of the 'canal is maintained and the expansion of the canal is usually localized with a definite epicenter unless the lesion is large. The expanding tumor may cause root resorption of adjacent teeth

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Treatment Excision is usually the treatment of choice

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 NEUROFIBROMA Synonym Neurinoma  Definition Neurofibromas are moderately firm, benign, well- circumscribed tumors caused by proliferation of Schwann cells in a disorderly pattern that includes portions of nerve fibers, such as peripheral nerves, Axons ,and connective tissue of the sheath of Schwann. As neurofibromas grow, they incorporate axons. In contrast, neurilemomas are composed entirely of Schwanncells and grow by displacing axons.

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 Clinical Features The central lesion of a neurofibroma maybe the same as the multiple lesions that develop in von Reckling- hausen's disease.Neurofibromas can occur at any age but usually are found in young patients. Neurofibromas associated with the mandibular nerve may produce pain or paresthesia.Neurofibromas also may expand and perforate the cortex; causing swelling that is hard or firm to palpation.

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Radiographic Features Location. in the mandibular canal, in the cancellous bone, and below the periosteum.  Periphery.. the margins of the radiolucency in neurofibromas usually are sharply defined and may be corticated. However, despite the benign nature and slow growth of the neurofibroma, some of these lesions have indistinct margins.  Internal structure. The tumors usually appear unilo- cular but on occasion may have a multilocular appearance. Effects on surrounding structures. A neurofibroma of the inferior dental nerve shows a fusiform enlargement of the canal

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Differential Diagnosis Differentiation from other types of neural lesions may not be possible.This tumor can be differentiated from Vascular lesions because the expansion of the canal is in a fusiform shape,'whereas vascular lesions enlarge the whole canal and alter its path.Treatment Solitary central lesions that have been excised seldom recur. However, it is wise to re-examine the area peri- odically, because these tumors are not encapsulated and someundergo malignant change

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NEUROFIBROMATOSIS Synonym von Reckling-hausen'sdisease  Definition Neurofibromatosis is a syndrome consisting of cafe au-lait spots on the skin, multiple peripheral nerve tumors, and a variety of other dysplastic abnormalities of the skin, nervous system, bones, endocrine organs, and blood vesselsThe two major classifications are NF-1, a generalized form, NF-2, a central form. Oral lesion may occur as part of NF-1 or may be solitary and are called segmental or forme fruste manifestations 91

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Clinical Features Neurofibromatosis is one of the most common genetic Diseases. The peripheral nerve tumors are of two types, schwannomas and neurofibromas. Most manifestations are appear gradually during childhood & adult life. Cafe-au-Iait spots become larger and more numer- ous with age; most patients eventually have more than six spots larger than 1.5 cm in diameter.

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Radiographic features The radiographic changes in the jaws with neurofibroatosis can be characteristic. These changes include 1.enlargement of the coronoid notch in either or both the horizontal and vertical dimensions2. an obtuse angle between the body and the ramus3. deformity of the condylar head 4.lengthening of the condylar neck5. lateral bowing and thinning of the ramus6.enlargement of the mandibular canal & mental and mandibular foramina and an increased incidence of branched mandibular canal

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Treatment Most patients live a normal life with Jew or no symp toms. Small cutaneous and subcutaneous neurofibro- mas can be removed if they are painful, but large plexiform neurofibromas should be left alone. Malignant conversion of these lesions has occurred in rare cases.

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MESODERMAL TUMORS  OSTEOMA Definition Osteomas can form from membranous bones of the Skull and face.The cause of the slowly growing osteoma is obscure, but the tumor may arise from cartilage or embryonal periosteumIt is not clearwhether osteomas are benign neoplasms or hamartomas Structurally, osteomas can be divided into three- types: composed of compact bone (ivory), composed of cancellous bone, composed of a combination of compact and cancellous bone.

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Clinical Features Age – above 40 yearsSex – Cortical type = men cancellous type= womenRadiographic Features Location. mandible -posterior aspect -lingual side of the ramus or on the inferior mandibular border below the molarsInternal structure. Osteomas composed solely of compact bone are uniformly radiopaque; those con- taining cancellous bone show evidence of internal tra- becular structure.  Effects on surrounding structures. Large lesions can dis- place adjacent soft tissues , such as muscles , and cause dysfunction.  

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Treatment Unless the osteoma interferes with normal function or presents a cosmetic problem, this lesion may not require treatment. In such casesthe osteoma should be kept under observation. Resection of osteoma sis possible and maybe difficult if the osteoma is of the cortical (ivory) type.

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CENTRAL HEMANGIOMA Definition A hemangioma is a proliferation of blood vessels creating a mass that resembles a neoplasm , although in many cases it is actually a hamartomaClinical Features Age – first decadeSex – femaleEnlargement is slow , producing a non-tender expansion of the jaw that occurs over several months or years. The swelling may or may not be painful, is not tender, and usually is bony hard. Pain, if present, usually of throbbing type

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Some tumors may be compressible or pulsate, and a bruit may be detected on auscultationAnesthesia of the skin supplied by the mental nerve May occur. The lesion may cause loosening and migration of teeth in the affected area. Bleeding may occur from the gingiva around the neck of the affected teeth. These teeth may demonstrate rebound mobility; that is,when depressed into their sockets,they rebound to their original position within several minutes because of the pressure of the vascular network around the tooth.Aspiration with a syringe produces arterial blood that maybe under considerable pressure..

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Hemangioma are associated with following Syndrome—Syndrome features

Rendu-osler-weber-syndrome

multiple telangi-ectasias ,occasional GI tract & CNS involvement

Sturge-weber-dimtri syndrome

Port-wine stain, leptomeningeal angiomas

Kasabach – merritt syndrome

Thrombocytopenic purpura associated with hemangiomas , consumptive coagulpathy , microangiopathic hemolysis , intralesional fibrinolysis

Maffucci syndrome

Hemangiomas of mucous membrane , dyschondroplasia

Von hippel-lindau syndrome

Hemangiomas of cerebellum , or retina, cyst of viscera

Klippel – trenaunay weber syndrome

Port-wine stain & angiomas of extremities 103

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Radiographic Features Locotion. Mandible , posterior body and ramus and within the inferior alveolar canal. Periphery. In some instances the periphery is well defined and corticated, and in other cases it maybe ill defined and even simulate the appearance of a malig- nant tumorThe formation of linear spicules of bone ema- nating from the surface of the bone in a sunray-like appearance can occur when the hemangioma breaks through the outer cortex and displaces the periosteum

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Internal structure. When there is residual bone trapped around the blood vessels ,the result maybe a multilocular appearance.Small radiolucent locules may resemble enlarged marrow spaces surrounded by coarse, dense ,and well-defined trabeculae . These internal trabeculae may produce a honeycomb pattern composed of small circular radiolucent spaces that represent blood vessels oriented in the same direc- tion of the x-ray beam.

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When the inferior alveolar canal is involved, the whole canal is increased in width and often the normal path of the canal is altered into a serpiginous shape Some lesions may be totally radiolucent. When the hemangioma involves soft tissue the formation of phleboliths (small areas of calcification or concretions found in a vein with slow blood flow) may occur within surrounding soft tissues They develop from thrombi that become organized and mineralized and consist of calcium phosphate and calcium carbonate.  

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Effects on surrounding structures. The roots of teeth in the region of the vascular lesion often are resorbed or displaced. When the lesion involves the inferior alveolar nerve canal, the canal can be enlarged along its entire length and its shape may be changed to a serpiginous path. The mandibular and mental foramen may be enlarged. Hemangiomas can influence the growth of bone and teeth. The involved bone may be enlarged and have coarse, internal trabeculae. Also, developing teeth may be larger and erupt earlier when in an intimate relationship with a hemangioma

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Differential Diagnosis Hemangiomas should be considered in the differential Diagnosis of multilocular lesions involving the body of the ramus and body of the mandible. Demonstration of involvement of the inferior alveolar canal is an important indicator of a vascular lesion.Treatment should be treated without delay, because trauma that disrupts the integrity of the Affected jaw may result in lethal exsanguination .Specifi- cally, embolization (introduction of inert materials into the lesion by a vascular route), surgery (en bloc resection with ligation of the external carotid artery), and sclerosing techniques have been used singly or together.

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ARTERIOVENOUS FISTULA Synonyms A-V defect, A-V shunt, A-V aneurysm, and A-V malformation Definition An arteriovenous (A-V) fistula, an uncommon lesion , is a direct communication between an artery and a vein that bypasses the intervening capillary bed. It usually results from trauma . The head and neck are the most common sites. 112

Page 113: Benign tumors of jaw

Clinical Features vary considerably, depending on the extent of bone or soft tissue involvement. The lesion may expand bone, and a mass may be present in the Extraosseous soft tissue. The soft tissue swelling may have a purple discoloration. Palpation or auscultation of the swelling may reveal a pulse. On the other hand, neither the bone nor the soft tissue maybe expanded, and no pulse maybe clinically apparent. Aspiration produces blood. Recognition of the hemorrhagic nature of these lesions is of utmost importance, because extraction of an associated tooth may be immediately followed by life-threatening bleeding.

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Radiographic Features Location.- ramus and retromolar area of the mandible and involve the mandibular canal.  Periphery.The margins usually are well defined and corticated.  Internal structure. A tortuous path of an enlarged vessel in bone may give a multilocular appearance. Otherwise the lesion is radiolucent.  Effects on surrounding structures. Both central lesions and those in adjacent soft tissue can erode bone, result- ing in well-defined (cystlike) lesions in the bone. Changes in the inferior alveolar canal may occur, as described in hemangiomas.  

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Treatment An A-V aneurysmis treated surgically.

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REFERENCES1.SHAFER’S ORAL PATHOLOGY2.NEVILLE ORAL PATHOLOGY3. ORAL radiology – white & pharoah4. burket’s ORAL medicine

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